Powerpoint Slide about Pain Relief

1. Roll No. 64 – Soe Myat Thwe
Roll No. 70 – SLNH
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PAIN RELIEF

2. What is Pain?
• Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage.
• Pain is a subjective one and is difficult to assess and
quantify.
• Pain perception varies from person to person and
from time to time
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Pain perception system

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5. Cause of Pain
• Inflammatory causes due to any infection or
infestations
• Hypoxia due to poor blood supply like in myocardial
infarction, peripheral vascular disease
• Trauma
• Obstruction like intestinal obstruction
• Colicky pain like ureteric, biliary, intestinal
• Compression over nerve roots like in inter vertebral
disc prolapse
• Advanced malignancies
• Ulcers, perforation, peritonitis, abscess formation
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6. Reasons to control postoperative pain/acute pain
• Uncontrolled pain causes tachycardia, hypertension
and vasoconstriction
• Abdominal (upper abdominal mainly) and thoracic
wound pain restricts the respiration causing
• tachypnea, altered respiration, coughing, chest
infection, pneumonia
• Persisting pain causes restricted movements, deep
venous thrombosis and its problems, bed sores
• Pain delays the recovery and also causes psychological
trauma to the patient
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CLASSIFICATION OF PAIN

8. Classification of Pain
According to Etiology
• Nociceptive pain: arises from inflammation and
ischemia
• Neuropathic pain: arises from a dysfunction in the
central nervous system
• Psychogenic pain: is modified by the mental state of
the patient
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According to Pain Intensity
• Mild: <4/10
• Moderate: 5/10 to 6/10
• Severe: >7/10
Pain rating scale is from 0 to 10.
• 0 = no pain
• 10 = the worst pain

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According to duration
• Acute pain: pain of less than 3 to 6 months duration
• Chronic pain: pain lasting for more than 3 to 6
months
• Acute on chronic pain: acute pain flare superimposed
on underlying chronic pain

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CLINICAL ASSESSMENT OF PAIN

12. Clinical assessment of pain
• Visual analogue scale: The patient indicates intensity of
pain on a line typically 10cm long marked from ‘no
pain’ at one end to ‘severe pain’ at the end. The pain is
scored in cm or mm.
• Faces scale
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• Non Linear scale : site, radiation, character, severity,
duration, frequency, special type of description,
aggravating factors, relieving factors, associated
problems
• Linear scale: The patient rates pain on a scale
typically from 0 (no pain) to 10 (severe pain).

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MANAGEMENT OF PAIN

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Management of Pain
Pharmacological Method
1. Regional techniques
2. Parenteral analgesia
• Patient controlled analgesia
• Opiates (morphine/pethidine), paracetamol
• Ketamine
3. Oral analgesia
• Paracetamol
• Nonsteroidal anti-inflammatory drugs
• Weak opiates(tramadol, codeine)
• Strong opiates (morphine)
4. Neuropathic pain

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1. REGIONAL TECHNIQUE

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REGIONAL TECHNIQUES
Common local anaesthesia techniques
Topical anaesthesia
• EMLA - mixture of lignocaine and prilocaine for
venepuncture in children
• Cocaine - nasal surgery
• Lignocaine 4% - during awake fibreoptic intubation
.

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Transversusabdominis plane block TAP - abdominal
surgery

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Intravenous regional anaesthesia (Bier’s block)
• Upper limb surgery
• Bupivacaine should never be used for Bier’s block

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Spinal anaesthesia
Epidural anaesthesia

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2.PARENTERAL ANALGESIA
3. ORAL ANALGESIA

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Patient-controlled analgesia
• Small dose of opioid
• Lock-out period allows the patient
to feel the effect of the opiate
bolus before administering
a subsequent dose minimizing
the amount of opiate consumed
and the risk of respiratory
depression

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Parenteral and oral opioid regimens
• Strong opioids – buprenorphine, fentanyl,
oxycodone, pethidine, morphine
• Side effect - respiratory depression, dysphora,
constipation, nausea and vomiting, pruritus,
urinary retention, and depressed conscious level
• Opioids can be reversed with naloxone
• Weak opioids - mild pain - codeine, dihydrocodeine
and tramadol
• Tramadol inhibits serotonin and noradrenaline
reuptake and is effective in neuropathic pain, and
acute pain setting

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Ketamine
• Ketamine is a noncompetitive agonist of acid (NMDA)
receptor
• Used in trauma particularly in the emergency
department or prehospital setting.

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Paracetamol
• oral, intravenous and rectal route
• Reduce opioid requirements by 20-30%
• In combination with NSAIDs, the combination is
more effective than NSAIDs alone
• Should use all postoperative patients except rare
contraindications.

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NSAIDs
• Combination with opioids, NSAIDs increase
analgesia
• Have an opioid-sparing effect, reducing
consumption, sedation
• Contraindication
 Renal impairment
 Impaired platelet function with the
potential for increased postoperative
bleeding
 Peptic ulceration
 Bronchospasm in individuals at risk

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4. NEUROPATHIC PAIN

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Neuropathic pain
 Ticyclic antidepressants
 Gabapentin
 Lidocaine
• 1.3% of patients
• Probably underestimated
• Risk factor for chronic neuropathic pain
• Expert advice should be sought as neuropathic
pain does not respond well to conventional
analgesia regimens
• Tricyclic antidepressants – used in chronic
neuropathic pain

30. Management of Pain(Non Pharmacological)
• Preoperative counseling
• Transcutaneous electrical nerve stimulation(TENS)
• Acupuncture
• Other methods
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31. Preoperative Counseling
• Management of postoperative pain includes not only
postoperative but also preoperative and intraoperative care.
• Inform the patient preoperatively as to the nature of
operation, likely postoperative pain and methods of analgesia
available.
• Assess the patient jointly with the anesthetist and nursing
staffs.
• Discuss the site and nature of surgery, extent of incision,
physiological and psychological status of the patient.
• Choose the most appropriate postoperative treatment plan.
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32. Transcutaneous electrical nerve stimulation(TENS)
• Consists of a pulse generator, an amplifier and a system of
electrodes.
• Acts by stimulating afferent myelinated (A-beta) nerve fibres
at a rate of 70 Hz.
• This activates the inhibitory circuits within the spinal cord that
reduce the transmission of painful nerve impulses to the
higher cortical centres thereby reducing the level of
postoperative pain.
• TENS has been shown to exert maximal relief in neurogenic
pain which is experienced in phantom limb pain and following
nerve damage.
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33. Transcutaneous electrical nerve
stimulation(TENS)
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34. Acupuncture
• Clinically evaluated in postoperative patients.
• But there is some variability in the way in which
acupuncture is administered.
• A number of studies suggest that it reduces pain and
analgesic consumption after dental and abdominal
surgery.
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35. Other methods
• Massage
• Hypnosis
• Application of superficial heat or cold
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CHRONIC PAIN MANAGEMENT

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PAIN CONTROL IN BEGIN DISEASE

38. Chronic Pain Control in Benign Disease
• Patient may have chronic pain from variety of
disorders including chronic inflammatory disease,
recurrent infection, degenerative bone or joint
disease,etc
• This pain results from persistent excitation of the
nociceptive pathways and sometimes not respond to
opiates or neuroablative surgery.
• Bring pain under control before amputation to avoid
phantom pain
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• Local anaesthetics and steroids injections -
effective around an inflamed nerve and
reduce cycle of constant pain transmissions
with consequence muscle spasm.
• Nerve stimulation procedures - increase
endorphin production in CNS.

40. Drugs in Chronic Benign Pain
• Paracetamol and non-steroid anti-inflammatory
drugs for musculoskeletal pain
• Tricyclic antidepressant drugs and anticonvulsant
agents for pain of nerve injury
• In very severe and debilitating non-malignant
chronic pain, opioid analgesic in many forms are
used
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PAIN CONTROL IN MALIGNANT DISEASE

42. Pain Control in Malignant Disease
 Pain is common symptom associated with cancer more in
advanced case.
 The World Health Organization’s booklet advises use of a
“pain step ladder”
• First step. Simple analgesics: aspirin, paracetamol,
nonsteroidal anti-inflammatory agents, tricyclic drugs or
anticonvulsant drugs.
• Second step. Intermediate strength opioids: codeine,
tramadol or dextropropoxyphene.
• Third step. Strong opioids: morphine (pethidine has now
been withdrawn).
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44. Neurolytic techniques in cancer pain
• These should only be used if the life expectancy is
limited and the diagnosis is certain.
The procedure are
• Subcostal phenol injection for a rib metastasis
• Coeliac plexus neurolytic block with alcohol for pain
of pancreatic, gastric or hepatic cancer
• Intrathecal neurolytic injection of hyperbaric phenol
• Percutaneous anterolateral cordotomy divides the
spinothalamic ascending pain pathway
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45. The Alternative Strategies
• The development of anti-pituitary hormone drugs,
such as tamoxifen and cyproterone, enables effective
pharmacological therapy for pain of widespread
metastases instead of pituitary ablation surgery
• Palliative radiotherapy can be most beneficial for the
relief of pain in metastatic disease.
• Adjuvant drugs, such as corticosteroids to reduce
cerebral edema or inflammation around a tumor,
may be useful in symptom control. Tricyclic
antidepressant, anticonvulsants and flecainide are
also used to reduce the pain of nerve injury.
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DANGER OF POOR PAIN RELIEF

47. Danger of Poor Pain Relief
• Respiratory effects
• Cardiovascular effects
• Neuroendocrine effects
• Effects on mobilization
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48. Respiratory effects
• Especially in upper abdomen and chest surgery
• Reduces vital capacity, functional residual capacity
and the ability to cough and deep breathe.
• Can lead to retention of secretions, atelectasis and
pneumonia.
• Inadequately treated pain aggravates these changes.
• Analgesia improves respiratory function.
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49. Cardiovascular effects
• Pain causes increase in sympathetic output
(tachycardia, hypertension and increasing blood
catecholamines)
• Leads to increasing myocardial oxygen demand
• May in turn increase the risk of postoperative
myocardial ischemia
• Especially in those patients with pre-existing cardiac
disease
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50. Neuroendocrine effects
• Stress response to surgery and pain includes the
secretion of catecholamine and catabolic hormones
• This increase metabolism and oxygen consumption
• Promotes sodium and water retention
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51. Effects on mobilization
• Mobilization of a patient in the postoperative period
may be delayed if the patient is experiencing pain.
• Increase the risk of developing a deep vein
thrombosis and also prolonged hospital stay.
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52. References
• Bailey & Love’s Short Practice of Surgery 26th edition
• Principle and Practice of Surgery 7th edition
• Davison’s Principles & Practice of Medicine 22nd edition
• Clinical Surgery in General 4th edition
• University of Wisconsin, Pain Management Project 2010
• Google images, Images from www.nysora.com
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